3 Things the Supreme Court’s ACA Ruling Means for Physicians

The Supreme Court of the United States delivered an historic decision Thursday morning, June 25, in King v. Burwell.

In a 6-3 decision, the justices ruled that subsidies should remain available for lower-income people who purchase their health insurance through the Affordable Care Act (ACA) marketplaces, regardless of whether their marketplace is maintained by the federal or state government.

This ruling affects physicians in three ways I’d like to highlight:

1. The decision supports our chief goal of helping patients stay healthy.

The Supreme Court’s ruling means that about 6.4 million people in the 34 states that did not create their own marketplaces will retain their ability to purchase coverage going forward. This is particularly important for low-income patients in states that did not expand their Medicaid programs. Without the subsidies, many of them could never afford health insurance.

As an emergency physician, I regularly see how important insurance coverage is to facilitate patients getting the medical care they need to recover from unexpected injury or illness. It also enables them to lead healthier, happier lives through better care of chronic diseases that can be devastating for them and their families.

The decision also means that insurance premiums will remain more affordable for most patients than would have otherwise been the case. A recent RAND study estimated that eliminating subsidies for patients who purchase their insurance through the federally run marketplace would result in a 47 percent increase in premiums. In such a scenario, a 40-year-old nonsmoker who purchased an unsubsidized silver-level plan would have needed to pay $1,610 more next year.

2. The decision lets us move forward.

With this case behind us, we as a profession and as a nation now must focus on the issue at the heart of health care reform: Ensuring every American has access to high-quality, affordable health care.

Regardless of differing opinions, access to high-quality, affordable health care is an issue we can all support. And by continuing to work together toward this end—whether through refining individual elements of the ACA, such as repealing the Independent Payment Advisory Board, or making changes to the current health care system—we can improve the health of all Americans.

3. The decision means we can turn our attention to improving the practice environment.

In moving forward, we must also devote our attention to transforming the practice environment so that both patients and physicians are healthier and more satisfied.

At the AMA, we’re working to enhance professional satisfaction and practice sustainability by pressing for relief from the tsunami of regulatory burdens that gets in the way of providing the highest-quality care for our patients. Among those burdens are the electronic health record meaningful use program, implementation of ICD-10 and the value-based payment modifier. Lawmakers, too, are now able to turn their attention to these pressing topics.

We’re also providing the tools physicians need to minimize professional stress and overcome barriers to providing the best possible care. Our newly launched STEPS Forward website offers a free online series of proven solutions that are developed by physicians to make practices thrive. We’ll be adding more modules over the coming months, so be sure to explore the website often.

Also, on the STEPS Forward website, we invite you to submit your own innovative solutions to clinical challenges to win $10,000 and help us create more modules to help physicians.

Even in these early years of health care reform, implementation of the ACA has affected much of the health care system. To examine this issue further, I encourage you to check out the July issue of the AMA Journal of Ethics, which takes a look at how patient care has changed in the era of health care reform.

Childhood Obesity in Washtenaw County

Local reports highlight positive trends and areas of concern
YPSILANTI, Mich., June 29, 2015 – Washtenaw County Public Health is pleased to announce the publication of new childhood obesity reports for Washtenaw County. They include an overall Washtenaw County report and community reports for Ann Arbor, Ypsilanti, Saline, Dexter, Chelsea, Whitmore Lake and Manchester.
Being overweight or obese in childhood increases the risk of obesity and other chronic diseases in adulthood. The reports show trends and identify factors that put local children at risk of being overweight or obese. They also provide a way to measure local progress.
“We want these reports to be as useful as possible for all of our partners working in the community to make a difference in children’s health,” says Laura Bauman, RN, MPH, epidemiology program manager with Washtenaw County Public Health. The reports are available at http://publichealth.ewashtenaw.orgThe Washtenaw childhood obesity surveillance project began in 2013. Through the Health Improvement Plan (HIP) collaborative, Washtenaw County Public Health worked with Saint Joseph Mercy Health System and the University of Michigan Health System to create the first Washtenaw Child Body Mass Index (BMI) Dataset.
Washtenaw County Public Health compiled and analyzed records for over 18,000 children, ages 2-17 years old, to create the local reports. Future waves of data will allow us to track progress of initiatives aimed at moving all children to a healthier weight.
Good News
Washtenaw County children as a whole have a lower rate of overweight and obesity than their counterparts nationally.
Local children of African American descent, however, surpass national rates. Children of African American descent as well as Hispanic and Latino children have the highest risk of being overweight or obese. This is a national trend that is reflected locally.
Analysis of the Washtenaw County data focused on factors known to affect the risk of childhood obesity, including poverty, race and ethnicity and age. Differences also exist depending on where children live within the county. 
Medicaid coverage is an indication of poverty. The risk of overweight and obesity was higher for children with Medicaid across all age groups and compared to children covered by commercial insurance.
There is some good news for local children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Rates of overweight and obesity in low-income WIC children declined between 2010 and 2014 (from 28% to 24% of WIC children age 2-4 years). The addition of peer educators to support local WIC moms in breastfeeding and changes in the WIC food package may have supported this trend.
Washtenaw County Public Health and the HIP partnership hope these reports will assist community leaders, clinicians, schools and others working to improve the health of children. With a greater understanding of which children in our community are most at risk of being overweight or obese, decision makers can direct local interventions and support where needed most. 


Top 5 Tips to Survive Severe Storms

University of Michigan Hospital emergency room physician Dr. Brad Uren, and Washtenaw County Medical Society President-Elect, has seen the aftermaths of severe storms and shared his top 5 tips to avoid becoming one of his patients in the ER.

1. Shelter

Like Bob Dylan, your first concern should be for shelter from the storm.

The safest rooms are located in basements, but those without should look for a closet, bathroom or other rooms with no windows on the ground floor.

Those living in mobile homes are particularly at-risk in severe weather events with strong wind. Uren said people in those communities should have a plan to reach more stable and secure structures quickly if a tornado is on the way.

Make sure everyone in your family knows where to go in case of a severe weather warning. If you have small children, it’s a good idea to have run family “drills” so everyone is prepared when the time comes to take cover.

2. Food and Water

Uren recommends having three days of food and one gallon of water per family member per day, including the family’s furrier members.

“People often don’t think about their pets when they’re planning for disasters,” he said. “If you don’t, then you’ll end up sharing your water and food and everyone comes up short.”

A first aid kit, a sharp tool to open cans and a hand crank radio also are on Uren’s list of things to have stocked in a safe room on the interior of the lowest available floor of your home.

3. Did you forget…

The tornado siren sounds in the middle of the night and you run downstairs to a room in your basement.

You’ve prepared for this, and the room is stocked with everything you might need. You have a first aid kit, plenty of food and enough water for you and your family.

But you can’t see any of it.

Uren said many people don’t remember to bring their glasses when they seek shelter.

“If you need those to function, you should make sure to have an old pair with all the rest of your emergency supplies,” he said.

While most people are aware of the necessary steps to take when severe weather strikes, Uren said they are often not fully prepared to deal with the aftermath of a very severe thunderstorm or tornado.

“One thing a lot of people don’t think about is their medications,” he said. “If there are meds you need, you have to make sure you have a few days supply with you. It can take up to 72 hours after a major disaster for help to arrive and refill those.”

It’s also important to remember basic necessities such as diapers if there are infants or toddlers in the home.

4. Cars are not (usually) the answer

Uren said the most dangerous urban legends about severe weather safety mostly have to do with cars.

“People think that if you’re in a car, the rubber tires will keep you safe from any lightning danger,” he said. “That’s just not the case.”

If you’re in contact with the metal frame of a car, you’re liable to receive any electrical shock that would come through the frame from a lightning strike. The strong burst of energy also can damage the car or even set parts of it on fire.

Cars are not fast enough to outrun tornadoes, and pulling over to the side of the road in a storm is only a good idea if you’re dealing with straight-line winds. One common misconception is that an overpass is a safe place to wait out a strong storm.

“Someone once got a video when they were able to pull over and stop under an overpass and they survived a tornado by getting up in between the steel girders,” Uren said.

“These days, most overpasses have concrete girders or you can’t even access them, and without that, an overpass is an incredibly dangerous place because of how the wind can get concentrated there.”

Of course, being in a car is still preferable to being out in the open and completely unprotected during a storm. The best thing to do is know when storms are coming so you can avoid being stranded.

5. Be serious and have a lot of back-ups

Do you have a flashlight? Stock up with extra batteries.

Is your cellphone fully charged? An external charging source is probably also a good idea.

Uren’s biggest message is that things can always go wrong, and even as we hope for the best, we should always prepare for the worst.

“These things can be very real,” he said. “Everyone near Ann Arbor will remember the Dexter tornado we had. We were very fortunate there were no fatalities and not a lot of serious injuries related to that.”

Don’t take severe weather warnings lightly, Uren said. Make sure to pay attention to local news and reports from the National Weather Service. Knowing when a storm is coming can give you enough time to take the proper precautions necessary to keep yourself and loved ones out of harm’s way.

MI Food Allergy Conference August 29 at the Kensington Court Ann Arbor Hotel

From our community partners at the Food Allergy & Anaphylaxis Michigan Association:

Physicians and other health care professionals are encouraged to attend this free 1/2 day conference on food allergy.  This program applies to the MI Board of Nursing rule 2(l) and reflects 4 hours of continuing education credit for RN’s.

Interdisciplinary speakers will cover a variety of topics related to IgE mediated food allergy with risk for anaphylaxis.  Please note conference content will not include information on other forms of adverse reactions to food such as food intolerance.

For more information on speakers, topics, sponsors, exhibitors, lodging, registration and continuing education credit is available at:

The conference is produced and managed by Food Allergy & Anaphylaxis Michigan Association (www.foodallergymiassociation.com). The conference is funded through a community grant from the nonprofit Food Allergy Research & Education (www.foodallergy.org)

Washtenaw County Amends Clean Indoor Air Regulation to Include E-Cigarettes: Changes Take Effect June 18

The use of electronic nicotine delivery systems, e-cigarettes or similar devices, will no longer be allowed in indoor public areas in Washtenaw County that are already smoke free. Changes to the Washtenaw County Clean Indoor Air Regulation were approved in March and take effect today, June 18, 2015.

New language in the regulation prohibits the use of electronic nicotine delivery systems in public and private worksites and other indoor areas open to the public, such as stores, public buildings, reception areas and public transportation. The 2015 amendment also extends the regulation to Washtenaw County Parks for the first time.

“The amended regulation treats electronic devices the same as traditional tobacco products in our shared, public spaces,” says Ellen Rabinowitz, MUP, health officer for Washtenaw County Public Health. “As the local public health authority, we are pleased with the changes. Relevant, up-to-date regulations that provide everyone with cleaner air to breathe are effective ways for us to protect and promote health in our community.”

Tobacco specialty shops and retailors specializing in e-cigarettes or other electronic smoking devices are exempt. Additionally, the county regulation does not address smoking or e-cigarette use in restaurants or bars, which are governed by Michigan’s Smoke-Free Air Law and have been smoke-free since 2010.

The current state law does not cover the use of e-cigarettes. Individual bars and restaurants, however, are free to set their own policies and can choose to ban e-cigarettes in the same way as traditional tobacco products.

“I’m delighted that the Washtenaw County Commissioners are in agreement with leading health authorities and have acted to include e-cigarettes and related devices in the Washtenaw County Clean Indoor Air Regulation,” says Jim Bergman, director of the Smoke-Free Environments Law Project, based in Ann Arbor.

According to Bergman, “The dangers of e-cigarette use and of secondhand e-cigarette aerosol in the air have been recognized by the American Medical Association, the American Heart Association, the World Health Organization, the National Institute for Occupational Safety & Health, the Centers for Disease Control & Prevention and many others. All of these health authorities have called for e-cigarettes to be treated in the same manner as traditional combustible cigarettes, including prohibiting their use where cigarette use is prohibited.”

Electronic Nicotine Delivery Systems

Electronic nicotine delivery systems are battery-powered devices that provide inhaled doses of nicotine or other substances by way of a vaporized solution. These devices are commonly called e-cigarettes, but also have other forms, such as e-cigars or e-hookahs. Most contain nicotine and resemble the act of smoking. Some varieties are flavored, which may increase their appeal to younger users.

E-cigarettes are currently not approved as smoking cessation aids and are not regulated. Exposure to the aerosol, chemicals and nicotine from these devices has not been proven safe for non-users to inhale. The amended regulation will protect county residents from involuntary exposure.

“E-cigarettes and similar devices are not regulated by the FDA,” says Alice Penrose, MD, MPH, medical director with Washtenaw County Public Health. “The amount of nicotine dispensed and the additives vary from brand to brand, and we do not have long-term data about the safety of these products for the people using them or those around them.”


Washtenaw County Public Health is responsible for enforcing the Washtenaw County Clean Indoor Air Regulation. Enforcement is driven by complaints. Residents who observe violations of the regulation may register a complaint by contacting DeBorah Borden, Tobacco Prevention Coordinator, at 734-544-6874 or bordend@ewashtenaw.org.

The text of the amended Washtenaw County Clean Indoor Air Regulation is available online.

New WCMS Website Under Construction – Stay Tuned!

New Website Launched for Opiate and Heroin Abuse in Washtenaw County


Opiate and Heroin Abuse in Washtenaw County

Washtenaw County has seen an increase in opiate overdose deaths since 2012.

Deaths related to opiate overdoses among Washtenaw County residents have increased. Opiates include both prescription painkillers and illicit drugs like heroin. Specifically, deaths involving heroin have increased steadily over the last several years.

opiate OD deaths image

Prescription painkillers are addictive and plentiful in the United States. Hydrocodone, for example, was the number one prescribed drug of any kind in the United States in 2013 according to the IMS Institute for Healthcare Informatics.

After becoming addicted to prescription painkillers, some may turn to heroin when prescription drugs become too costly or too difficult to get.

Overdose deaths involving fentanyl have also increased. Fentanyl and fentanyl-like substances that are made illegally can be up to 100 times more powerful than morphine and 50 times more powerful than heroin, according to the United States Drug Enforcement Agency.

Fentanyl may stop a victim’s breathing almost instantly. It may be found alone or in combination with heroin or other drugs.

The Opioid Project

In response, the Washtenaw County Opioid Project is a collaboration promoting effective solutions based on local data. It brings together law enforcement, public health, hospitals, community mental health, treatment facilities, other providers and community leaders to share resources, build partnerships and combat the epidemic. Washtenaw County Public Health co-leads the Opioid Project in partnership with the Washtenaw Health Initiative.

Opiate Overdose Deaths among Washtenaw County Residents

Summary by gender, age and type of opiate: Opiate Overdose Deaths among Washtenaw County Residents, 2011-2014

During the first quarter of 2015, there were 16 opiate overdose deaths among Washtenaw County residents. Fentanyl was found (alone or in combination with heroin) in seven of these deaths (44%).

2015 Jan-March April-June July-Sept Oct-Dec
Heroin 9
Fentanyl 7
Prescription opiates 3
Total Deaths*  16      

* Some individuals test positive for more than one type of opiate.

Emergency Hospital Admissions Associated with Opiate Overdoses

Washtenaw County Public Health reviews emergency room admissions from local hospitals attributed to opiate overdoses.

From April 2011 to March 2015, over 400 county residents were admitted to University of Michigan or Saint Joseph Mercy hospitals for overdoses associated with opiates. Individuals admitted for unintentional heroin overdoses tend to be younger and male (average age was 32 years and 87% were white). Individuals admitted for unintentional prescription opiate overdoses were older, female (60%) and predominately white (average age 51 was years and 81% were white).

Table by quarter April 2011 – March 2015: Emergency Department Admissions for Unintentional Opiate Overdoses – Washtenaw County Residents Admitted to University of Michigan or Saint Joseph Mercy Hospitals.

Hepatitis C

Hepatitis C is a viral illness spread through contact with contaminated blood. Washtenaw County has seen an increase of new infections among young people. New infections are almost all due to intravenous drug use. Blood transfusions are now screened for Hepatitis C and are not a potential source of infection.

Summary of 2014 Hepatitis C cases: Hepatitis C Trends 2014

Graph of Newly Diagnosed Hepatitis C Infection in 18 – 29 yr olds Washtenaw County residents* 2007-2014.

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Childhood Obesity Profiles

The publication of the first round of childhood obesity data profiles for Washtenaw County is now available.  The data and these reports are a result of collaboration between St Joseph Mercy Health System, University of Michigan Health System and Washtenaw County Public Health.

Please take a look at this important new surveillance project for our community: